HomeMy WebLinkAboutApp-Permit-ComplianceNo.$7:1d,3......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........................................O F....`�X. �...............................
Appliration for Disposal Murks Tonstrudi-111t fermi#
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System 1,1,41C'✓2 j &j - -
...f :.S :.G..ti.�»..�...n../ + re s ................................
a �y �� Owner
Installer
Type of Building
D
-
twK.
.....--.-a.1'•-�o..........................................__..............
Ig................Address..........................................
Address
Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other —Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures...............................•-•-•--------------.....--•--•---------•--..._.....--•--•---------•--•-•---•------._.........---•..................---•
Design Flow ............................................ gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank - Liquid ' ca.pacity......_._...gallons Length .....:.......... Width ................ Diameter ................ Depth ................
Disposal Trench — No . .................... Width .................... Total Length .................... Total leaching area ...................sq. ft.
Seepage Pit No ..................... Diameter .................... Depth below inlet .................... Total leaching area .................. sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date ........................................
Test Pit No. 1 ................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
Descriptionof Soil ........................................................................................................................................................................
-•----------------------•----•-----......._........----------...---•-••-----•-•---•----...•--•--=-••••---•------------••---•-•- ........•----..............
Nature of Repairs or Alterations - Answer when applicable _._ �. ��_. .. �..`.:�.� ..{!... ............................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance hag been issued by0e boar of health.
Application Approved By ...........
Application Disapproved for the
t ..
..ya._...
Permit No.. -O./- - - .... Issued. ' /'
---------------------• Date ...Dau ......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF..... �`..........................................
�)
&rfifirate of Toutplinurr
THIS IS TO CE Y, That the Ind* 'dual Sewage Disposal System constructed.( ) or Repaired (
._...... ,< < •- . v ......- =- }............... ........................................................ ............................
O �. �4 Installer�d /�/�
at.. --•-•--._.....3.. �..............®..(........... w� - -.................... r�/-.................................................�\:...-
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary ode desc i ed in the
application for Disposal Works Construction Permit No._�.7:_J�3..................... date - -___ .�C2�Cf._. V-8
ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED ASA 4UARANTEE THAT THE
SYSTEM WILL FUNCTION ,SA41-SFACTORY. �
DATE ................. .. --- .... .......----•----•--- •-- -+ ....._.......-----..................._......
..: .r. % Inspector. " /